Supporting geriatric patients through orthopaedic surgery with Dr Nargis Shaheen

This podcast focuses on the complexities of managing surgical patients in the elderly demographic, emphasizing the critical nature of preoperative assessments and the need for tailored approaches to care. The speaker highlights the increasing prevalence of elderly patients undergoing surgery and the associated heightened risks, including complications such as organ dysfunction, cognitive decline, and functional impairment. Given these factors, it is imperative to adopt a well-rounded approach that encompasses thorough risk-benefit analyses and shared decision-making between healthcare providers and patients.

A significant portion of the discussion revolves around the necessity of comprehensive preoperative evaluations. The speaker underscores the importance of understanding each patient’s unique health profile, including their comorbidities and medication regimens. With aging comes numerous physiological changes that can adversely affect surgical outcomes, such as reduced cardiac reserve, diminished lung capacity, compromised renal function, and the prevalence of sarcopenia. These age-related factors necessitate the use of specific risk assessment tools, among which the clinical frailty scale and comprehensive geriatric assessment are highlighted as particularly effective in evaluating elderly patients' fitness for surgery.

The lecture elaborates on the clinical frailty scale, a method for assessing patient fitness ranging from robust health to terminal illness. The speaker prefers the comprehensive geriatric assessment for its holistic view, capturing not just medical history but also functional status, cognitive abilities, nutritional conditions, and social factors. Identifying potential complications before they arise allows for tailored interventions that address the specific needs of elderly patients, such as nutritional support and medication adjustments. The speaker notes the importance of nutritional status, particularly considering the risk of sarcopenia and acknowledging that a significant portion of elderly patients experience nutritional deficiencies that may impact their surgical recovery.

Another key aspect discussed is medication reconciliation, where potential risks associated with multiple medications are assessed, particularly those that could contribute to postoperative complications such as bleeding or delirium. A proactive approach, which might include changing medications in collaboration with general practitioners, is necessary to minimize these risks. The necessity for clear communication about the surgical process, associated risks, and expected recovery is underscored, with emphasis placed on the value of preoperative counseling in improving patient satisfaction and enhancing their preparedness for surgery.

The speaker also touches on the importance of addressing patient preferences and treatment goals during the pre-admission clinic visits. Quality of life often takes precedence over longevity for many elderly patients, and understanding these goals is vital to providing personalized care. Furthermore, the speaker highlights the need to assess post-discharge support systems to ensure a smooth recovery process at home, which may include planning for rehabilitation services if needed.

In wrapping up, the speaker reaffirms the critical role of geriatric preoperative assessments in reducing complications and ensuring favorable outcomes among elderly surgical patients. Enhanced perioperative care, which has gained recognition in the medical community, is presented as a pivotal element in managing the challenges posed by this unique patient population. The discussion emphasizes the ongoing efforts to integrate geriatric considerations into surgical practices and underscores the commitment to improving the overall quality of care for elderly patients facing surgical interventions.

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This gentleman has come to me, and my job is to try to get him through the surgery

and see what he actually wants.

And after discussing with him, is he still going to proceed to surgery?

And also identifying what factors would influence his surgical and perioperative approach.

So we know that people are living much longer.

And undergoing surgery. Now,

surgery in the elderly patients always carries increased risk of complications

such as organ dysfunction, cognitive decline,

delirium, and functional decline as well.

Therefore, it's very vital that we optimize these patients prior to surgery

and proceed to surgery with shared decision-making and informed decisions.

The main key factor for this is to have a comprehensive risk-benefit analysis

with consideration of every individual's overall health.

Also take into consideration the type of surgery they are going through and

the utilization of multidisciplinary team, which specializes and has good experience

with the elderly patients.

And we should remember that these patients are generally multimorbid and on many medications.

Besides, I always remember that

with age comes physiologic changes in all organs for elderly patients.

So elderly patients do have reduced cardiac reserve, which increases their risk

of fluctuating blood pressure, arrhythmias.

They have decreased lung capacity, which also increases the risk of pneumonias

and respiratory failure.

The reduced filtration rate of the kidneys increases the risk of fluid and electrolyzed imbalance.

Age-related cognitive reserve is very poor in elderly patients,

which increases the risk of delirium and can lead to rapid cognitive decline.

Besides, sarcopenia is very common in elderly.

They do have reduced muscle mass and strength, which increases their risk of

falls and slower recovery.

When I see these patients, how do we assess them?

There's various risk assessment tools.

There's been NSQIP, surgical risk calculator.

However, good evidence to suggest that in elderly people, clinical frailty scale

and comprehensive geriatric assessment are the best.

Now, clinical frailty scale is a good screening tool.

It assesses from one to nine,

which is one very fit, they are robust, they are fit for their age,

while as the nine is the terminally ill, with in between various functional

declines, those who require minimal assistance or require assistance with all ADLs.

For my benefit, I prefer the comprehensive geriatric assessment because it allows

me to see the patient as a holistic management.

You include the functional status, the cognitive function, nutritional status,

and medication review, besides the review of all the comorbidities and additionally

social function as well.

We tend to identify the predicted complications and tailor the interventions

as per what the underlying comorbidities are.

The preoperative assessment is the best time to also address nutritional status,

given that there is significant sarcopenia in elderly patients.

Not everyone, but there are at least 30 to 40% who will have nutritional deficiencies.

We tend to advise protein supplements because there is not sufficient time in orthopedic surgery.

It's more to do with immediate interventions rather than try to do prehab.

But sometimes it is important to delay

the surgeries and involve a multidisciplinary team for prehab as well.

Again, preoperative clinic assessment also allows us to adjust patients' medications,

Quite often, looking at the medication reconciliation,

especially the prescribed and over-the-counter medications,

quite often you will see that patients are on multiple medications that could

predispose them to bleeding, like fish oil, glucosamine,

and all the other multiple medications they take.

Also, to minimize the risk of post-operative

delirium, to reduce the anticholinergic burden in these people,

we do tend to provide a written...

Directions and for the patients to change the medications.

And if necessary, we do involve general practitioners as well.

It is very important to provide clear information, potential risks and expected

recovery in these patients.

We have had multiple consumer surveys where good patient satisfactions have

been advised after with patient counselling.

So, advanced care directive or also getting a healthcare proxy while in the

pre-admission clinic to see what the expected cause and possible complications,

discuss with the patient and their family so that they are not surprised at

the end when such complications happen.

We also, in the pre-admission clinic, tend to identify the treatment goals with

the patient and also ensure that the patient preferences and expectations are met.

Quite often, the patients will come and tell you that they prefer quality of life over longevity.

So that needs to be also taken into consideration.

Identifying the post-discharge support system at home,

because quite often these patients will leave the hospital with possible delirium

and will also have difficulty with completing their activities of daily living.

So, it's very vital to see that they do have support system or do they need rehab after surgery.

These are all identified in the pre-admission clinic and patients are given

all the information before they leave.

I often find that seeing these

patients in the clinic and discussing about the risk of delirium or risk of

reduced mobility does improve the patient communication and their expectations.

And quite often we get feedback that we are happy that this has been previously

discussed with us because now we know what to expect.

All this is much better identified on comprehensive geriatric assessment rather than using other tools.

However, if the patient is not very complicated, then clinical frailty skills should be sufficient.

The optimal geriatric preoperative assessment, which is the comprehensive geriatric

assessment, as mentioned, does include the assessment of cognitive impairment and dementia,

the decision-making capacity, the depression or mood-related problems,

which can affect postoperative recovery, postoperative delirium.

If patients have had previous delirium or they've got a history of dementia

or mild cognitive impairment, that needs to be identified.

Preoperatively identify the alcohol and substance abuse.

As mentioned, cardiac and pulmonary evaluation, functional status,

mobility and false risk.

Frailty is also a consideration, and clinical frailty scale can identify that.

As mentioned, nutritional status, medication management, and discharge planning.

Oh, sorry.

The main things to remember is that there's good... I still have time,

so I'll just quickly say some things.

The main thing to remember is that there is good evidence now for perioperative

medicine and care for elderly patients.

Previously, we didn't have much perioperative care,

but I've been doing this for a long time, And we have been advocating for perioperative

assessments for elderly patients for a long time to a point where now we do

have a formal chapter of medicine in the anaesthetist college.

And there's a formal perioperative medicine chapter now, which many even general

practitioners are doing.

Of course, we were one of the initial ones and got through the perioperative

medicine through grandfather clause.

But managing patients, elderly patients is one of our main issues and we would

like to continue managing them with adequate,

reducing the complications and discharging with a good support system as well

as reducing inpatient complications.

Thank you very much. I believe you.